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风湿性心脏病与非风湿性心脏病患者三尖瓣置换的病例对照研究

目的分析三尖瓣置换患者的流行病学特征、治疗及随访情况，探讨提高三尖瓣置换疗效的策略。方法回顾性分析 2009 年 8 月至 2016 年 10 月 20 例在我院行三尖瓣置换患者的临床资料。男 4 例、女 16 例，年龄 31～73（54.4±2.2）岁。根据病因学分为风湿性心脏病组（14 例）及非风湿性心脏病组（6 例），比较两组患者术前情况、治疗方法、治疗结果及随访情况的差异。结果本组围手术期死亡 3 例，住院病死率 15.0%。死亡原因均为多器官功能衰竭。术后对 17 例出院患者进行了随访，随访率 100.0%，随访时间 1～84 个月，随访期间共有 2 例死亡。风湿性疾病组与非风湿性疾病组术前存在心房颤动/心房扑动心律（P=0.001）、术前有心脏手术史（P=0.017）、手术中是否进行主动脉阻断（P=0.032）差异有统计学意义。结论尽管风险较大，三尖瓣置换仍是针对器质性三尖瓣病变的有效手段，但需严格掌握手术指征及手术时机。风湿性三尖瓣疾病具有更多的危险因素，尤其是既往有左心瓣膜手术史继发三尖瓣关闭不全的患者。

Interpretation of the 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease

The 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease not only updates aortic valve stenosis, mitral regurgitation, prosthetic valves, infective endocarditis and antithrombotic treatment on the basis of the 2017 guidelines update for valvular heart disease, but also involves aortic valve regurgitation, bicuspid aortic valve, mitral stenosis, tricuspid regurgitation, combined valve disease, pregnancy with valvular disease, valve disease complicated with coronary heart disease, valve disease complicated with non-cardiac surgery and the prospect of comprehensive management of valve disease. It covers a wide range of contents, which are introduced in detail and comprehensively. This paper interprets some highlights and core issues, including the top 10 take-home messages, the severity of valvular heart disease, and the updates in the management of aortic valve stenosis, aortic valve regurgitation, bicuspid aortic valve, mitral stenosis and mitral regurgitation.

直视双极射频消融术治疗心瓣膜病合并慢性心房颤动

目的 介绍直视双极射频消融术治疗心瓣膜病合并慢性心房颤动（AF）的初步体会，探讨控制慢性AF的有效方法。 方法 2005年5月至2007年11月，对23例心瓣膜病合并慢性AF患者采用直视双极射频消融术治疗，在常温体外循环心脏跳动下进行右心房的消融，然后在中度低温心脏停搏下做左、右肺静脉口和左心耳的消融隔离，最后行心瓣膜置换术。 结果 射频消融时间18～26 min。术后因特发性血小板减少致消化道大出血住院死亡1例，生存的22例患者随访3～30个月，出院时、3个月、1年和2年窦性心律转复率分别是81.8%、86.4%、82.4%和77.8%，无Ⅲ度房室传导阻滞、病窦综合征和栓塞等并发症发生。 结论 直视双极射频消融术治疗心瓣膜病合并慢性AF操作简单、效果满意、并发症较少。

米力农对合并肺动脉高压瓣膜病患者体外循环期间肺氧合功能的影响

目的 探讨体外循环(CPB)期间米力农对心脏瓣膜病患者肺氧合功能是否具有保护效应及预给药对肺保护作用的影响。 方法 将30例合并肺动脉高压瓣膜病患者，按照米力农的给药方法不同随机分为3组，每组10例。Ⅰ组、Ⅱ组分别于麻醉诱导前、CPB后并行阶段泵入米力农，泵速均为0.5μg／kg·min；对照组给予生理盐水，以相同速度泵入。于麻醉诱导后（T1）、开胸时（T2）、停CPB（T3）、术毕（T4）及术后4h（T5）测定3组的血流动力学和血气指标，计算氧合指数(OI)和肺内动静脉分流率（Qs/Qt）。 结果 3组患者T1时肺动脉收缩压(SPAP)、肺血管阻力(PVR)和Qs/Qt均高于正常,组间比较差异无统计学意义（Pgt;0.05）。与T1比较，T2时各指标差异无统计学意义，在T3、T4、T5后各时点心脏指数(CI)均明显增高（Plt;0.05）；PVR、SPAP逐渐降低（Plt;0.05）；Ⅰ组停机后OI值较T1增高（Plt;0.05），Qs/Qt降低（Plt;0.05）。在T3、T4、T5时，Ⅰ组的PVR，Qs/Qt和OI与其它两组同期比较差异有统计学意义（Plt;0.05）。 结论 米力农能够改善重症心脏瓣膜病患者CPB期间肺部氧合功能，术前预给药可能有利于发挥肺保护效应。

急诊外科手术治疗危重心瓣膜病192例

目的 总结危重心瓣膜病患者行急诊手术的临床经验，以提高其疗效和治愈率。 方法 自1996年10月至2007年11月对192例危重心瓣膜病患者施行了急诊手术。所有患者均为心瓣膜病合并严重心力衰竭，心功能分级（NYHA）为Ⅲ~Ⅳ级。经内科治疗2~7 d无效时采取急诊手术治疗；行二尖瓣置换术76例次，主动脉瓣置换术64例次，双瓣膜置换术43例次，三尖瓣置换术4例次，三尖瓣成形术45例次，左心房血栓清除和左心房减容 术各5例次，冠状动脉旁路移植术5例次，其他心血管手术9例次。 结果 术中和术后早期分别死亡3例和8例，总手术死亡率为5.7%（11/192），主要死亡原因为术中不能脱离体外循环机、术后发生低心排血量综合征和突发心室颤动等。随访168例，随访时间1个月~11年，失访13例。随访期间死亡8例，主要死于左心衰竭、瓣周漏或心内膜炎复发、尿毒症、夹层动脉瘤等。长期生存160例，心功能恢复至Ⅰ级132例，Ⅱ级15例，Ⅲ级13例；生活质量较术前有所提高。 结论 危重心瓣膜病患者经内科治疗无效时急诊手术具有良好的疗效，是较好的治疗选择。

风湿性心瓣膜病二尖瓣置换术中并发血管麻痹综合征一例

合并心脏恶病质瓣膜病的外科治疗

目的 为提高合并心脏恶病质瓣膜病患者外科治疗的成功率，探讨其围术期处理的特点。方法 符合心脏恶病质综合征诊断标准的21例心瓣膜病患者接受了手术治疗，其中二尖瓣置换术14例，主动脉瓣及二尖瓣置换术7例，同时三尖瓣成形术16例。结果 发生并发症13例，分别为低心排血量综合征、室性心律失常和多器官功能衰竭等；死亡6例，主要死亡原因为多器官功能衰竭。结论 合并心脏恶病质瓣膜病患者的外科治疗应注意围术期处理；术中应重视三尖瓣功能纠正及左、右心房折叠；术后注意低心排血量的治疗，积极防治多器官功能衰竭，加强营养支持。

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.

Application and Significance of Coronary Angiography Prior to Heart Valve Replacement for Patients with Rheumatic　Valvular Heart Disease

Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.

重症风湿性心瓣膜病的外科治疗